Typology. According to the Oxford English Dictionary (sorry Mirriam-Webster, I’m English, not American; although here, both have the same definition) is “A classification according to general type, especially in archaeology, psychology, or the social sciences.”

Amusingly, it can also be defined as “The study and interpretation of types and symbols, originally especially in the Bible.” As I’m in no way going to be analysing the Bible (the greatest work of fiction ever devised), the former definition applies. Here, it refers to this paper, and after reading the abstract my initial reaction was to award it with the “Pointless Research Award”.

In the interests of fairness, I’m going to shelve that initial reaction, be open-minded and thus comment on the substance of the paper itself. Should be interesting.

Aside from the usual soundbites in the introduction to the paper (read Tobacco smoking remains a global pandemic, affecting an estimated 1.2 billion people and causing nearly six million deaths annually and other such soundbite material), this line caught my attention:

More specifically, it seeks to identify differing accounts of e-cigarette use/vaping and the dimensions on which they vary.

On the surface, this seems like a good idea. Scientists bothering themselves with trying to understand a segment of the population. In this case, vapers.

This paper then offers a situated analysis of these accounts within wider discourses concerning harm reduction, the medicalization of addictive behaviours, the pleasure dimension as well as users’ identity (or not) as vapers.

From that, I can glean the researcher will be looking at three main areas:

The Pleasure Principle

Medicalisation

Not Bothered (Ambivalent)

Interestingly, this is – as far as I am aware – the first paper to broach the subject of the Pleasure Principle regarding vaping, which in itself is a revelation, although I doubt many within public health & tobacco control circles will lend that aspect of this paper any substantial credence whatsoever. It doesn’t fit their narrative.

There is one point reference in the introduction that I want to highlight as it does characterise the debate rather succinctly:

It is not clear that further research into e-cigarettes will substantially alter opinion. This is because the dangers stem not merely from the constituents of the products themselves, but the ideological challenge they pose…

Which, to my mind, nails the essence of the entire debate. On one side there are the proponents that have a fundamental ideological view that e-cigs are a good thing, and on the other, there are the opponents that fundamentally believe e-cigs are a “public health threat”. Thus, this paper endeavours to clarify a few points about vapers.

Reducing the risk or harm levels of smoking is a key motivator for many vapers, whether they quit smoking entirely.

Well, who would have thought that? It’s not like this hasn’t been investigated elsewhere now, is it? There are many papers that mention vapers wanting to reduce the risk by switching to, either completely or partially, e-cigarettes.

Although this paper is trying to approach the debate from a social science perspective, the author notes:

Perceptions that e-cigarettes are safer than smoking may also be declining over time (Huerta, Walker, Mullen, Johnson, & Ford, 2016). The reasons for this change in risk perceptions are not known.

Which is rather disingenuous when there is a near constant barrage of piss-poor articles in various media outlets – both online and in print – as well as the usual suspects being given substantial airtime to spout meaningless nonsense. To attribute the decline to poor reporting of (even worse) science and the useful idiots spouting meaningless drivel on the airwaves (and via the telly-box) is, in itself, disingenuous. The scope of misinformation being peddled is much broader than that, but it is safe (relatively speaking, natch) to assign a large proportion of the blame at the piss-poor science and the even worse reporting of said science.

The author also highlights the “quit-or-die” attitude prevalent within tobacco control:

Harm reduction, where moral judgement on drug use is avoided and treatment aims to reduce risk, has gained widespread traction within the field of drug policy (Marlatt, Larimer, & Witkiewitz, 2012). However, as Stimson (2016) has argued, unlike the co-ordinated public health response to the HIV/AIDS threat, harm reduction has been positively discouraged from within tobacco control.

This subject was broached at GFN last year – it was mentioned in the same breath that us advocates should look toward a global organisation (Hello INNCO) and that organisation looking to become an official ‘Observer’ for the FCTC (never going to happen!), but it is – seemingly – being recognised within other science circles, that tobacco control have forgotten (probably deliberately) one of the founding principles of the FCTC – harm reduction. Instead, a good deal of tobacco control organisations and individuals demonstrate the “quit-or-die” mentality.

Further, to the risk perception, medicalisation and pleasure principles, the author tried to understand who vapers are – the “identity” as it were:

A final aspect of understandings of e-cigarettes relates to identity. Smoking has shifted in terms of social meaning in recent decades from a glamorous alluring habit to a polluting addictive behaviour that harms others. Correspondingly, the identity of ‘being a smoker’ has become a matter for moral judgement and stigmatisation. Moving from seeing oneself as a smoker to an ‘ex’ or ‘non-smoker’ has been argued to be a key transition supporting successful quitting.

In summary, the social science literature has started to delineate many features of vapers’ understandings of their practices. However, gaps remain, and it is not clear how different aspects of vapers’ thinking, such as beliefs about risk, medicine, identity and politics in relation to e-cigarettes, intersect or ‘make sense’ as coherent viewpoints.

Here’s a problem. It’s a large problem. It’s one inherent in any e-cigarette research, and it’s one that I’ve covered many times before, and no doubt I’ll end up having to cover it over, and over again.

Selection & confirmation bias. True, to understand what motivates an individual that identifies as a vaper, you would need to ask them about it. However, I remember this being study being passed around by several people I know – many of whom would be classified by this paper as “Factor One: Vaping as a pleasure” – I decided to not get involved with it at the time, for the simple reason is I am wary of research in this field and for good reason. As for confirmation bias, the author points out where this study was advertised:

Surprisingly, the number recruited from vaping forums is lower than I would expect, but then that would entirely depend on which forums and most importantly, how the advert was worded. Many forums, and I do not speak from experience here, aren’t always welcoming for that type of advert.

When developing a set of statements to use in this type of study, an understanding of the area being investigated should be a prerequisite; although not always feasible for researchers to have a thorough grounding in the subject they are researching, but a top level overview would be nice. Here, the author and one other researcher operated independently in the initial stages, reading as much of the public, academic, and social media (including blogs, article comments – gee, I bet that was fun – and vaping forums) content on e-cigarettes as possible.

Here’s another minor flaw:

Relevant statements were also adapted from a previous Q study on smoking and social identity

As with the NYTS in the US, and the STS in the UK, many of the original questions in those surveys on e-cigarettes were adapted from similar questions on smoking. Which of course can lead to a whole host of confusion and misinterpretation.

Judging from the statements used in this Q set, I have to wonder which fora the researchers actually visited. Sadly, there isn’t any reference in the paper on how the researchers arrived at the final 70 statements, no details on social media searches, blogs visited, vaping forums visited, academic sites & papers reviewed. Nothing. Aside from the papers references to support various statements, there’s nothing to indicate the methodology for the statements used.

In terms of numbers of participants, this study would be categorised as “small”:

Participants were 55 current e-cigarette users/vapers from the UK. Thirty were male (55%) and 25 female (45%), 96% self described their ethnicity as ‘white’, with two ‘mixed’ and ‘mixed white/black Caribbean’. The mean age was 46 (range 19–69). In terms of socio-economic status (SES), 27 held professional employment, 23 non-professional employment, one unemployed, two people having disabilities and two students.

It is, of course, highly likely that the author decided to limit participation to the UK only – it originated from the University of Exeter after all, and there was a £10 gift voucher upon return of the study pack.

Knowing the UK as well as I do, it is likely that I know many of the 55 participants and that nigh on all of them would be frequent forum visitors – with a few exceptions. Remember, this paper is not meant to be at all representative of the UK vaping populace, it does represent the views of the participants (mostly) – which would explain the prevalence of pleasure.

In this account, e-cigarettes were characterized not only an effective substitute for tobacco cigarettes (39: +5; 28: 6), but an enjoyable one. E-cigarettes were superior to NRT or other cessation treatments (65: +4), with few side-effects (40: 4). Numerous stories of successful quitting were recounted.

As noted in the study text, the pleasure wasn’t just isolated to the sensory experience of vaping, but was likened to “having your cake and eating it”. Amusingly, the participants grouped into “Factor One” actively rejected medicalisation of e-cigs, rejecting the whole “nicotine is addictive” and going as far as commenting ‘Medicine? I assume medicine is intended to treat an ILLNESS- I am not ill!!!’

Well, a simple trawl through most vaping fora, blogs and social media, in general, would highlight this, along with a healthy dose of common sense. Some studies have already touched on the enjoyment factor of vaping; not many admittedly, but there have been some – mostly those looking at usage by youth.

Not surprisingly, “Factor One” participants were those likely to label themselves as a vaper (not that there’s anything wrong with that), and (according to the paper) evangelical about e-cigarettes:

For them, to be a vaper was to be part of ‘a community who are supportive of one another and I’m proud to be one of them’

Even less of a surprise is those in this factor were also highly interested in activism and had a “high political interest”.

Not a surprise at all. The most vocal advocates do tend to be highly politically motivated, following the debate as closely as they are able and are usually highly active in spreading factual information – or at least, countering misinformation – wherever they can.

As for “Factor Two: Vaping as Medical Treatment”, well, again, a dose of common sense would apply here. Simply put, the figures from the UK stop smoking services that are e-cig friendly, coupled with the steep rise in e-cigs as the most popular cessation method noted in the Smoking Toolkit Study operated by Robert West, would suggest a number of smokers-turned-vapers do view the products solely as cessation aids.

Let us not forget a recent, though flawed, meta-analysis by everyone’s favourite mechanic claimed e-cigs don’t help cessation, while an analysis of EU data suggests otherwise. There has been a number of studies on “e-cigs for cessation”, yet not one of them asked participants what they thought of the products, merely if they used them to stop smoking.

It didn’t help that the headlines surrounding the PHE Evidence Update in 2015 focussed on having e-cigs (potentially) made available on prescription (not ever likely to happen).

Does knowing how individuals view the medicalisation of e-cigs provide any beneficial insight? I sincerely doubt it in all honesty.

Finally, we approach “Factor Three: Ambivalent E-Cigarette Use”. Out of the small sample, only 6 fell into this factor. This isn’t to say these 6 individuals were ambivalent to e-cigarettes in general, just towards their own use of the product, and seemingly, they appeared to be dual-users, reporting both vaping and smoking; switching between the two for various reasons.

On the flip side, those ambivalent towards their own use seemingly had stronger leanings towards the assertion of vaping rights:

The Factor Three account represented a more ambivalent attitude towards e-cigarette use. On the one hand, there was a strong assertion of vaping rights; it is the right of adults to decide to vape (17: +5; 13: +6), including in public as they are not causing harm to anyone (64: +5).

As with data from the various “harm perception” style surveys, the participants of ‘Factor Three’ weren’t clear that e-cigarettes had benefits and were generally fairly neutral about their impact on their quality of life or any potential side-effects.

Data like this has been available, in varying forms, for a while now. As much as I distrust ASH, much of the UK data on harm perception and so forth comes from them. I seem to recall another study from Scotland that also reached similar conclusions.

The results suggest that a typology of accounts of vaping can be identified which varies on key dimensions, namely the role of pleasure/enjoyment, the acceptance of a medical model of nicotine addiction, the acceptability of long-term use, identifying as a ‘vaper’ and political interest in vaping rights.

If the paper focussed solely on the pleasure/enjoyment aspect of vaping, much as The Pleasure of Smoking report did, then it would go a long way to supporting the products as the lifestyle products that they are. I would guess that there would now be a need for research to see if pleasure and enjoyment affect food choice, or holiday destinations, or friendships, or anything else that we might derive pleasure from.

Instead, by looking at medicalisation and ambivalence this paper has now opened the door for “targeted health promotion/regulation that resonates with its target audience” :

given the need to incorporate user views and design health promotion/regulation that resonates with its target audience (Joffe, 2002). The implications of such heterogeneity for tobacco control is now explored.

This paper may have some limited benefit, but in all actuality it is mostly fluff. Amusingly, this is the type of information that can be gleaned via normal, everyday discourse. The kind that many in tobacco control simply do not want to have. The fact it is now a peer-reviewed paper – for whatever that is worth – is a small plus point.

Just to prove my earlier bias point:

In this study, Factor One is likely to be dominant as those who are the most ‘evangelical’ about vaping may also be the most motivated to take part in vaping research. Those who are ambivalent and/or still smoke are likely to be under-represented.

Of course, that limitation will likely be overlooked by many. It is, of course, the same limitation that the Pleasure of Smoking suffers, along with many other survey-like studies. Limited usefulness.